Question:
What is the medical criteria for abdominoplasty?

My plastic surgeon sent in a letter with pictures for predetermination of abdominoplasty and I was denied based on pictures sent and didn't meet the medical criteria for the abdominal surgery. Can anyone out there tell me what kind of medical criteria needs to be met in order to be approved for an abdominoplasty through BC/BS PPO? Can anyone e-mail me their appeal letter for an abdominoplasty or any other information I might need to appeal the insurances decision of denial? BC/BS wouldn't tell me what their medical criteria was. Any help would be greatly appreciated. Please e-mail to [email protected] thanks.    — Barbara M. (posted on November 10, 2003)

November 10, 2003
AppeAL!! I had BCBS and was told it 'wasnt medically necessary' at the first level. I appealed, talked to the person doing the second level (didnt give any more information than they had on the first) and was approved. At level one bcbs had an 'urologist' review the request... DUH! I had 11 pounds removed; the panni did have 'skin breakdown' and they wanted to know if I had been to a doctor - which I hadnt I 'self' medicated... good luck
   — star .

November 10, 2003
I have BCBS United of WI which is a POS contract but the criteria is the same for any of their policies. I got a denial also but they left the door open and seem to try to lead me down a path. I do not have an approval yet but should hear this week. The denial I got said that it "appeared" to be cosmetic however they would review it again once I reached the weight I wanted to maintain. They also said they wanted and orthpedic evaluation and recommendation and new pictures. We are trying to argue the need due to my long standing low back problems that have been worse since I am getting more active and have so much hanging skin. Normally they just deny and don't say anything. We have sent back a detailed letter from my neurosurgeon, orthopedic surgeon, WLS surgeon and the PS. The first two docs focused on my low back problems. The best I can determine is that they wanted an orthopedic evaluation done to determine if there was a functional issue that removing the skin could solve or improve. The bottom line is have pretty bad degenerative disc disease in 4 discs and getting any excess strain off the low back has to help some. But they didn't seem to want to hear it from a neurological standpoint, only orthopedic. I hope now that they have been provided it they will approve. <p>My experience with BCBS is that they need proof of medical necessity. In other words that it is causing some other medical problem and that getting rid of the skin will eliminate or substantially improve the medical problem. Severe rashes that won't respond to treatment are the other likely thing that would get an approval. If they do not approve it this time I will appeal and build my case from the standpoint that this is a logical and cost effective way to help manage my low back problem. I no longer can live on anti-inflammatories, I can only get 3 epidurals in a year at a cost of about $1500 ea. and that they no longer provide the degree of relief they used to. I have done PT and electric stim. All with some results but nothing makes it totally go away. The ortho surgeon indicated that once the skin and fat was gone I would be able to better strengthen the abdominal and low back muscles etc. <p>The bottom line is BCBS does not see the need to remove the excess skin as medically necessary in it of itself. One way or another mine is hitting the road. I may be poor but my gut won't be like something out of a horror movie.
   — zoedogcbr

November 10, 2003
I've found the best picture you can send them is you standing to your side and grabbing your stomach and pulling it out as far in front of you as possible. This truly shows them how much excess skin you have. It worked for me. I have BC/BS and they approved me after receiving this picture.
   — Patty H.